by Susan Perloff
“Take two aspirin and e-mail me in the morning.”
At the University of Pennsylvania Health System, patients with questions are encouraged to e-mail their health-care providers instead of phoning them. And the doctors e-mail back. It’s a technical revolution that all parties appreciate!
Currently, about 240,000 people actively use myPennMedicine (mPM), the institution’s secure electronic portal that allows patients to submit questions, read test results, and request appointments online. Between December 2009 and April 2015, electronic messages to and from patients soared from zero to almost two million a month. That’s a lot of phone calls avoided and office paper saved.
Patients and most providers like both the 24/7-ness of the electronic system and its directness, which make it the opposite of whispering down the lane. Any literate, clear-thinking patient can submit a clinical message without fear of distortion and expect an educated, medically sound response within a few days.
An example of cloud computing, mPM allows doctors and their staffs to communicate with patients and their families in a new, efficient way. It’s the health-care equivalent of ordering a pizza, a pillow, or a party dress from home. A patient can schedule a Pap smear, request a prescription renewal, or find the dates of upcoming appointments from a desktop, smartphone, or tablet.
Susan C. Day, M.D. ’77, G.M.E. ’81, is a professor of clinical medicine, primary-care provider, director of population health for the Division of General and Internal Medicine, and associate chief medical information officer (CMIO) for the Penn Medicine’s patient portal and population health.
According to Day, patients, especially younger ones, like the ability to stay up-to-date on health maintenance, refills, and easy referrals without unnecessary trips to the doctor’s office. They even like receiving test results, which sometimes arrive in an inbox without adequate explanation. That, too, is changing, with new access to the Healthwise online library, which explains and interprets lab tests.
“We have just turned on the ability for patients to send in data on their weight, blood pressure, step count, and blood sugar by linking mobile devices, such as Apple Watch, scales, blood pressure cuffs, and glucometers, through the patient portal.” Day says this technology “should help us manage chronic conditions like diabetes and high blood pressure.”
Penn’s electronic medical records (EMR), called PennChart, went live in 1998. The software comes from EPIC, a private company in Wisconsin that serves large medical groups, hospitals, and integrated health-care organizations. Ten years later, the system first allowed patient interaction.
Scott Schlegel, M.B.A., associate vice president for EMR integration at Penn, co-chairs the myPennMedicine efforts with Day. At present, mPM handles only ambulatory-care data within Penn’s EMR system. Schlegel notes that the service receives more than 500,000 messages each quarter. More than three-fourths of UPHS employees have accounts, plus 21,000 in the 13-to-17-year-old range, from such areas as family medicine, dermatology, and sports medicine. More than half the users are 50 or older, and, amazingly, 14 people over 100 – or their caretakers – have tried the Penn portal. Usage is accelerating rapidly.
mPM flourishes at four Penn hospitals: HUP, Pennsylvania Hospital, Penn-Presbyterian Medical Center, and Chester County Hospital. “It transforms how we practice and how we do research,” Day says. “It has huge potential.”
“Your Mailbox Was Full”
myPennMedicine is a boon for practitioners. Neil R. Malhotra, M.D., G.M.E. ’09, assistant professor of neurosurgery at Penn and director of the Neurosurgery Quality Improvement Initiative, is an enthusiastic user. “When I remove a tumor from a patient’s brain, of course I want to be sure that the procedure goes smoothly,” he says. “But I also want to be sure that the patient understands what’s going on and is able to participate in their ongoing care. That’s one of the ways I use myPennMedicine.”
Malhotra calls mPM “remarkable for patient empowerment.” As he sees it, “There’s no time for clinicians to spend time during a complex physical exam explaining every detail to a patient. But if my patients look at reports and lab tests online before they come in, we can have more constructive conversations. During a repeat visit, I can explain why their numbers matter.”
With this system, he continues, “rather than leaving my office and forgetting what I said, they can now ask whether their potassium level could possibly relate to their cramps. They may not understand cell biology, but they are more empowered than without the online information. If you’re a little bit scared, you’re a little more likely to remember what we say on that topic.”
Managing prescription refills no longer needs to occur face to face. “So mPM frees valuable time for us to focus together on their care,” he says.
Michael A. Ashburn, M.D., M.P.H., M.B.A. ’05, professor of anesthesiology and critical care and director of the Penn Pain Medicine Center, also values mPM. “It allows me to look at a patient request and respond without having to track the patient by phone,” he says. “If it’s a simple request like a refill, I can send it to the pharmacy electronically, notify the patient, and close the loop in one interaction. It interferes less with my routine clinical practice.”
When Ashburn phones patients, he says, “At least 30 percent of the time the patient doesn’t answer or there’s a bad connection or they have forgotten why they called. Then they want an appointment, and I have to refer them to someone else to schedule.” According to Ashburn, mPM allows physicians to respond more effectively and efficiently to half the inquiries. “That gives us more bandwidth to handle the calls that need to be made.”
If a patient doesn’t present adequate information when querying online, Ashburn can request more: “If the message requires the participation of other team members, or prior authorization, or a myriad other scenarios, sometimes I can respond and route the message to others.” For a refill when Ashburn is unavailable, a staff member can authorize a partial supply and recommend a repeat visit to discuss the medication and/or dosage with the doctor.
“And I have a paper trail,” Ashburn points out, “which is still important, not only for legal reasons, but also to resolve prior questions. Like a patient complains that no one called them back, and you look at the file and say, ‘I called you back on April 1, but your mailbox was full.’”
Patient Portals in Other Major Medical Centers
While the administration is justly proud of myPennMedicine, Penn is not alone among major medical centers in providing electronic communication between physicians and their patients.
• Yale’s “My Chart” system, which closely parallels mPM, allows patient-physician communication, prescription renewals, access to test results, and views of recent clinic visits.
• Johns Hopkins, which purchased the framework for its “My Chart” from Epic, went live in 2013.
• Mayo Clinic combines elements of the GE and Cerner patient portals with its own features. It also has a mobile app for Apple, Android, and Kindle platforms for its “Patient Online Services.” About 700,000 patients currently have online accounts.
• Harvard uses multiple electronic platforms for its multiple hospitals, private practices, and student health.
“Remember to Schedule Your Flu Shot”
Beyond direct doctor-patient messages, myPennMedicine reminds enrolled patients about appointments and inoculations. Not long ago, women had to remember to schedule their own mammograms. Now e-mails alert them. Sometimes watchful patient find errors in their own records.
Two years ago, Penn Medicine’s senior leaders approved converting all clinical care and billing activity at all Penn Medicine locations to EPIC. Phase One, completed early in 2015, brought emergency care, transplantation, and radiology on board, says Schlegel. Part of Phase Two, which involves bringing inpatient clinical documentation, pharmacy, hospital billing, and home-care settings onto the single medical record, should be complete by October 2016. The rest is scheduled to be complete by March 2017.
Ashburn acknowledges that mPM cannot serve every patient in every situation. Some people need to refill potent opioids, which is not possible via the patient portal. “Sometimes patients try to use mPM to address urgent issues, but the system is not prepared for that.” And although the portal posts clear warnings that it is not intended for emergency care, some patients still may expect rapid answers. “We respond throughout the day, but no one is dedicated to responding all day long, so the patient may not receive an immediate answer.”
For all its benefits, says Day, the patient portal raises issues about health and age disparities, computer access and literacy. It will never be possible to switch all patients or all discussions to the Web. “Initially this feels like extra work. We need to teach physicians and staff that answering e-mails is just as important and needs to be just as quick as a phone call – and that may mean that there’s different work, not more work.”
Some providers and staff members are concerned that electronic communications might destroy the barriers that shield them from being overwhelmed by patient needs. And some points of resistance remain for physicians, such as:
• Informing patients about complicated test results, such as chest x-rays that suggest cardiomegaly (an enlarged heart, often resulting from high blood pressure or coronary artery disease).
• Coordinating one patient’s care across multiple practices.
• Staffing the mPM queries. Determining which staff person handles which questions.
Day says that each hospital-based medical practice strives to be a “patient-centered home,” a new buzzword. As such, it coordinates and delivers care, and it shares health information, including by the most current technology. Patients might come in three or four times a year, she says, but between visits, lots of treatment and prevention efforts occur. myPennMedicine enables the interactions.
Some national research praises online patient portals. A 2012 Kaiser Permanente study showed that patients with access to their online records used their health-care system more than people who opted out of a portal. Ted E. Palen, Ph.D., M.D., the study’s lead author, did note that portal participants might have been more concerned about their health than those who didn’t enroll, a situation that would account for some difference in usage.
A 2015 literature review in the Journal of Medical Internet Research concluded that patient portals show significant improvements in how patients managed their chronic diseases (although “sociodemographic disparities exist for portal use”). In addition, such portals seem to offer great potential for higher quality care.
As the Penn Med experience shows, the electronic system can also function as a way to conduct patient surveys. Ashburn’s office sends patients an after-visit summary with instructions for answering questions. “We are reasonably aggressive in collecting patient-outcome data, particularly how intense their pain is,” he says. “These answers are very important to us.”
Schlegel expects that patient-reported outcomes will change as more people participate on mPM. Questionnaires and USB-enabled devices – such as glucometers, blood pressure cuffs, and scales – can directly download information into a portal that care teams can use. All this without a need for office visits or, indeed, any direct contact.
Day and Schlegel are looking at ways to inform interested patients about participating in research studies that might be relevant to them.
The Health Kit app on iPhones can link directly to Penn’s site, and additional software is developing. “The software and the interface can be intimidating” because it’s new, says Day. “There’s a learning curve for everyone.”
No, myPennMedicine is not perfect. Patients have legitimate beefs, such as these:
There can be a lot of variability in how quickly and how carefully offices deal with patient requests, says Day. One of her colleagues encouraged his mother to participate. The woman expressed frustration when she sent a message to her provider and received a “your message has been received and forwarded” auto response from the office – but there was no actual follow-up from her provider. She vowed never to use the system again.
According to Ashburn, “My patients get frustrated when they use mPM and then are told they need to call to resolve the issue, or when it takes several messages to adequately resolve the issue. When a patient sends a message about a health issue that leads to the physician suggesting they come in, they then say, ‘O.K., please book me.’ My response is, ‘I don’t know how, please call. . . .’ And they have to call again or go back into mPM again. I certainly understand their annoyance.”
An advisory committee, comprising patients and advocates, evaluates these types of issues and makes recommendations for improving the processes.
Schlegel is looking ahead. “It took a long time for electronic communications to come to health care,” he says. Some medical centers put physicians’ notes on their electronic charts. But, he adds, doctors’ notes have traditionally remained behind the curtain. “We’re not pushing for that right now.” He sees the future of mPM as adding bill paying and enhancing functionality. Another possibility: visits via video.
“It’s a rapidly evolving and exciting world,” Day says. “It engages the whole medical team – doctors, nurses, nurse practitioners, social workers, front desk, and, most importantly, patients – in designing better ways to access and deliver care. It’s not perfect, but it has a lot of potential. This is my soapbox.”
And perhaps not far off: “Take two aspirin, sit in front of your computer screen, and say ‘Aaah.’”